Review Question - QID 204540

This patient with melena and abdominal pain has peptic ulcer disease secondary to chronic NSAID use for osteoarthritis. Because her pain is worse with eating and NSAIDS are likely implicated, a gastric ulcer is more likely than duodenal ulcer.

Gastric ulcers often occur in older patients. H. pylori and chronic NSAID use are the most common causes. In contrast, almost 100% of duodenal ulcers are due to H. pylori infection. Pain from Gastric ulcers is often Greater with meals, while pain from Duodenal ulcers often Decreases with meals. Potential complications include bleeding, penetration into the pancreas, obstruction, and perforation.

Ramakrishnan et al. discuss the features of peptic ulcer disease. Peptic ulcers classically present with epigastric discomfort. Pain may even cause awakening at night, loss of appetite, and weight loss. Older patients and patients with alarm symptoms indicating a complication or malignancy should have prompt endoscopy. Patients taking NSAIDs should discontinue their use.

Meurer et al. discuss the management of H. pylori. Triple therapy includes omeprazole, a proton pump inhibitor, metronidazole or amoxicillin, and clarithromycin for 10 to 14 days.

Illustration A shows a punched-out peptic ulcer.

Incorrect Answers:
Answer 1: Duodenal ulcers often decrease in pain with meals.
Answer 3: A lower gastrointestinal bleed would present with bright red blood per rectum, not melena.
Answer 4: Squamous cell carcinoma of the esophagus classically occurs in the upper 1/3 of the esophagus and presents with dysphagia to solids and/or liquids, not abdominal pain.
Answer 5: A patient with a perforated peptic ulcer would classically appear with an acute abdomen. In contrast, this patient has had symptoms in a more chronic time course.